CLM-2026-009996
Mesa Family Practice, Family Medicine. Service 2025-10-31 at office (POS 11). Received 2026-04-19.
Member
Resolved through the identity graph
- Member
- Ana Robinson
- Member ID
- UHC-45904-17
- Date of birth
- 1955-02-02
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-410399
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6756
- Coverage period
- 2025-06-01 to present
- Deductible
- $373.13 of $1,500.0025%
- Out-of-pocket maximum
- $831.67 of $6,000.0014%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3505890145
- Network
- In network
- Rendering NPI
- 3274446921
- Location
- Atlanta, GA · TIN 15-9233501
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 36415 | Venipuncture | — | 1 | 1 | $19.00 | $11.78 | — | — | DeniedCO29 |
| Totals | $19.00 | $11.78 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-768828
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020998 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-10-31: MEDICARE-ADV-B (MA), effective 2025-06-01. | |
| Timely filing | Fail | CO29 | Received 170 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Family Practice (3505890145). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Family Practice2025-10-31 15:02
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-19 00:51
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 170 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001654 | 2026-10-02 | Lakeside Internal Medicine Associates | $236.00 | Needs review |
| CLM-2026-001653 | 2026-10-02 | Lakeside Internal Medicine Associates | $236.00 | Approved |
| CLM-2026-003267 | 2026-08-01 | Valley Bone and Joint Center | $6,306.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.